Healthcare Provider Details

I. General information

NPI: 1003274697
Provider Name (Legal Business Name): OUR SPACE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1527 W NATIONAL AVE
MILWAUKEE WI
53204-2141
US

IV. Provider business mailing address

1527 W NATIONAL AVE
MILWAUKEE WI
53204-2141
US

V. Phone/Fax

Practice location:
  • Phone: 414-383-8921
  • Fax: 414-383-9016
Mailing address:
  • Phone: 414-383-8921
  • Fax: 414-383-9016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. JENNIFER MEDEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 414-383-8921